NICE TB guideline

Tuberculosis

This Guidelines summary focusses on the prevention of tuberculosis. Please refer to the full guideline for recommendations on treatment, infection control, case finding, adherence, treatment completion and follow-up, and service organisation

Preventing tuberculosis

Raising and sustaining awareness of TB

Among health professionals and those working with high‑risk groups

Multidisciplinary TB teams (in collaboration with Public Health England, primary care, the voluntary sector, and Health Education England) should identify and support an ongoing TB education programme for local professionals in contact with the general public, and at‑risk groups in particular. This includes, for example, staff in emergency departments, GPs and wider primary care staff, people who work in housing support services, staff who support migrants and those working in walk‑in centres, hostels, substance misuse projects, and prisons

Multidisciplinary TB teams should ensure the education programme increases other professionals' awareness of the possibility of TB and reduces the stigma associated with it. The programme should include detail on:

causes of TB, how it is transmitted, and the signs and symptoms

lifestyle factors that may mask symptoms

local epidemiology, highlighting under-served groups, other high-risk groups and the fact that TB also occurs in people without risk factors

Principles of TB control:

early diagnosis and active case-finding

how to support treatment (including directly observed therapy)

drug resistance

awareness of drug interactions (including factors such as effect on contraception efficacy)

contact investigation after diagnosing an active case

the importance of adhering to treatment

treatment for TB is free for everyone (irrespective of eligibility for other NHS care)

social and cultural barriers to accessing health services (for example, fear of stigma and staff attitudes)

local referral pathways, including details of who to refer and how

the role of allied professionals in awareness‑raising, identifying cases and helping people complete treatment

misinformation that causes fear about TB, including concerns about housing people with the condition

the best ways to effectively communicate all the above topics with different groups

Statutory, community and voluntary organisations and advocates working with the general public, and under‑served and high‑risk groups in particular, should share information on TB education and awareness training with all frontline staff. (They should get information on this from the local multidisciplinary TB team.)

If possible, statutory, community and voluntary organisations should ensure peers from under‑served groups and anyone else with experience of TB contribute to, or lead, awareness‑raising activities. (Peers who lead such activities will need training and support.)

Among high‑risk groups

Multidisciplinary TB teams should help professionals working in relevant statutory, community and voluntary organisations to raise awareness of TB among under‑served and other high‑risk groups. These professionals should be able to explain that treatment for TB is free and confidential for everyone (irrespective of eligibility for other NHS care). They should also be able to provide people with details of:

how to recognise symptoms in adults and children

how people get TB

the benefits of diagnosis and treatment (including the fact that TB is treatable and curable)

location and opening hours of testing services

referral pathways, including self‑referral

the potential interaction of TB medication with other drugs, for example, oral contraceptives and opioids (especially methadone) and HIV treatment

TB/HIV co‑infection

how to address the myths about TB infection and treatment (for example, to counter the belief that TB is hereditary)

how to address the stigma associated with TB

the risk of migrants from high‑incidence countries developing active TB – even if they have already screened negative for it

contact tracing

Multidisciplinary TB teams and others working with at‑risk groups should use high quality material to raise awareness of TB

Multidisciplinary TB teams and others working with the general public, and with under‑served and other high‑risk groups in particular, should include information on TB with other health‑related messages and existing health promotion programmes tailored to the target group

Multidisciplinary TB teams should work in partnership with voluntary organisations and 'community champions' to increase awareness of TB, in particular among under‑served groups at risk of infection but also in the general population. If possible, peers who have experience of TB should contribute to awareness‑raising activities and support people in treatment

Providing information for the public about TB

National organisations (for example, National Knowledge Service—Tuberculosis, TB Alert, Public Health England, Department of Health and NHS Choices) should work together to develop generic, quality‑assured template materials with consistent up‑to‑date messages. These materials should be made freely available and designed so that they can be adapted to local needs

Multidisciplinary TB teams should use these templates for general awareness raising and targeted activities in under‑served and other high‑risk groups. Involve the target group in developing and piloting the materials

The content of any materials should:

be up to date and attractively designed, including pictures and colour if possible

be culturally appropriate, taking into account the language, actions, customs, beliefs, and values of the group they are aimed at

be tailored to the target population's needs

include risks and benefits of treatment, and how to access services, advice and support

dispel myths

show that, by deciding to be tested and treated for TB, a person can be empowered to take responsibility for their own health

use language that encourages the person to believe that they can change their behaviour

be simple and succinct

Make the material available in a range of formats such as written, braille, text messages, electronic, audio (including podcasts), pictorial, and video. Make them freely available in a variety of ways, for example, online, as print materials, or on memory sticks

Disseminate materials in ways likely to reach target groups, for example, via culturally specific radio or TV stations, at shelters, and at community, commercial, or religious venues that target groups attend regularly

BCG vaccination

To improve the uptake of BCG vaccination, identify eligible groups (in line with the Department of Health's Green Book opportunistically through several routes, for example:

new registrations in primary care and with antenatal services, or other points of contact with secondary or tertiary care

people entering education, including university

links with statutory and voluntary groups working with new entrants and looked‑after children and young people

during contact investigations

When BCG vaccination is being recommended, discuss the benefits and risks of vaccination or remaining unvaccinated with the person (or, if a child, with the parents), so that they can make an informed decision. Tailor this discussion to the person, use appropriate language, and take into account cultural sensitivities and stigma

If people identified for BCG vaccination through occupational health, contact tracing or new entrant screening are also considered to be at increased risk of being HIV‑positive, offer them HIV testing before BCG vaccination

BCG vaccination in neonates (0–4 weeks)

Identify and vaccinate pregnant women eligible for vaccination (in line with the Green Book) before the birth of their baby, ideally through antenatal services

Discuss neonatal BCG vaccination for any baby at increased risk of TB with the parents or legal guardian

Preferably vaccinate babies at increased risk of TB before discharge from hospital or before handover from midwifery to primary care. Otherwise, vaccinate as soon as possible afterwards, for example, at the 6‑week postnatal check

Incorporate computer reminders into maternity service (obstetrics) IT systems for staff, to identify and offer BCG vaccination to babies eligible for vaccination

Provide education and training for postnatal ward staff, midwives, health visitors and other clinicians on identifying babies eligible for vaccination, local service information and providing BCG vaccination, including:

case definition for at‑risk groups to be offered vaccination

information about the local BCG vaccination policy that can be given verbally, in writing or in any other appropriate format (see Raising and sustaining awareness of TB and Providing information for the public about TB, above) to parents and carers at the routine examination of the baby before discharge

local service information about BCG vaccination, such as pre‑discharge availability of neonatal vaccination, local BCG clinics and referral for BCG vaccination if this is not available in maternity services

administration of BCG vaccination and contraindications

Primary care organisations with a high incidence of TB should consider vaccinating all neonates soon after birth

In areas with a low incidence of TB (see Public Health England's TB rate bands, published in their Annual Report, primary care organisations should offer BCG vaccination to selected neonates who:

were born in an area with a high incidence of TB or

have 1 or more parents or grandparents who were born in a high‑incidence country or

Routine BCG vaccination is not recommended for children aged 10–14 years:

healthcare professionals should opportunistically identify unvaccinated children older than 4 weeks and younger than 16 years at increased risk of TB who would have qualified for neonatal BCG and provide Mantoux testing* and BCG vaccination (if Mantoux‑negative)

this opportunistic vaccination should be in line with the Green Book

Mantoux testing should not be done routinely before BCG vaccination in children younger than 6 years unless they have a history of residence or prolonged stay (more than 1 month) in a country with a high incidence of TB

BCG vaccination for new entrants from high‑incidence areas

Offer BCG vaccination to new entrants who are Mantoux‑ or interferon‑gamma release assay‑negative who:

are from high‑incidence countries and

are previously unvaccinated (that is, without adequate documentation or a BCG scar) and

are aged:

younger than 16 years or

16–35 years from sub‑Saharan Africa or a country with a TB incidence of 500 per 100,000 or more

Encouraging uptake among infants, older children and new entrants

Deliver the following interventions in primary care settings to improve uptake of BCG vaccination in people from eligible groups (as outlined in the Green Book):

reminders ('immunisations due') and recall ('immunisations overdue') for people who are eligible for vaccination or for parents of infants and children who are eligible, as outlined in the Green Book. (This could include written reminders, telephone calls from a member of staff or a computerised auto dialler, text messages or a combination of these approaches)

Use home visits to give information and advice to people who are disadvantaged on the importance of immunisation. This should be delivered by trained lay health workers, community‑based healthcare staff or nurses

BCG vaccination for healthcare workers

Offer BCG vaccination to healthcare workers and other NHS employees who have contact with patients or clinical specimens, irrespective of age, who:

are previously unvaccinated (that is, without adequate documentation or a BCG scar) and

are Mantoux‑ (or interferon-gamma release assay‑) negative

BCG vaccination for contacts of people with active TB

Offer BCG vaccination to Mantoux‑ (or interferon‑gamma release assay‑) negative contacts of people with pulmonary and laryngeal TB if they:

have not been vaccinated previously (that is, there is no adequate documentation or a BCG scar) and

are aged 35 years or younger or

are aged 36 years and older and a healthcare or laboratory worker who has contact with patients or clinical materials

BCG vaccination for other groups

Offer BCG vaccination to previously unvaccinated, Mantoux‑ or interferon‑gamma release assay‑negative people aged 35 years or younger in the following groups at increased risk of exposure to TB, in accordance with the Green Book:

veterinary and other staff such as abattoir workers who handle animal species known to be susceptible to TB, such as simians

prison staff working directly with prisoners

staff of care homes for older people

staff of hostels for people who are homeless and facilities accommodating refugees and asylum seekers

people going to live or work with local people for more than 3 months in a high‑incidence country

Preventing infection in specific settings

Healthcare environments: new NHS employees

Employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check, or documentary evidence is provided of such screening having taken place within the preceding 12 months

Employees new to the NHS who will not have contact with patients or clinical specimens should not start work if they have signs or symptoms of TB

Health checks for employees new to the NHS who will have contact with patients or clinical materials should include:

Employees who will be working with patients or clinical specimens and who are Mantoux‑ or interferon‑gamma release assay‑negative should have an individual risk assessment for HIV infection before BCG vaccination is given

Offer BCG vaccination to employees of any age who are new to the NHS and are from countries of high TB incidence, or who have had contact with patients in settings with a high TB prevalence, and who are Mantoux‑ or interferon‑gamma release assay‑negative

If a new employee from the UK or other low‑incidence setting, who has not had a BCG vaccination, has a positive Mantoux test and a positive interferon‑gamma release assay, they should have a medical assessment and a chest X‑ray. They should be referred to a TB clinic to determine whether they need TB treatment if the chest X‑ray is abnormal, or to determine whether they need treatment of latent TB infection if the chest X‑ray is normal

If a prospective or current healthcare worker who is Mantoux‑ (or interferon‑gamma release assay‑) negative declines BCG vaccination, explain the risks and supplement the oral explanation with written advice. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations

Screen clinical students, agency and locum staff and contract ancillary workers who have contact with patients or clinical materials for TB to the same standard as new employees in healthcare environments, according to the recommendations set out above. Seek documentary evidence of screening to this standard from locum agencies and contractors who carry out their own screening

NHS trusts arranging care for NHS patients in non‑NHS settings should ensure that healthcare workers who have contact with patients or clinical materials in these settings have been screened for TB to the same standard as new employees in NHS settings

Healthcare environments: occupational health

Include reminders of the symptoms of TB, and the need for prompt reporting of such symptoms, with annual reminders about occupational health for staff who:

are in regular contact with TB patients or clinical materials or

have worked in a high‑risk clinical setting for 4 weeks or longer

Give one‑off reminders after a TB incident on a ward

If no documentary evidence of previous screening is available, screen staff in contact with patients or clinical material who are transferring jobs within the NHS as for new employees

Assess the risk of TB for a new healthcare worker who knows he or she is HIV‑positive at the time of recruitment as part of the occupational health checks

The employer, through the occupational health department, should be aware of the settings with increased risk of exposure to TB, and that these pose increased risks to HIV‑positive healthcare workers

Healthcare workers who are found to be HIV‑positive during employment should have medical and occupational assessments of TB risk, and may need to modify their work to reduce exposure

* At the time of publication (January 2016) the BNF states: 'The Mantoux test is recommended for tuberculin skin testing, but no licensed preparation is currently available. Guidance for healthcare professionals is available at www.dh.gov.uk/immunisation.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.